13. Bhutanese Refugees in Nepal

There are approximately 96,500 Bhutanese refugees registered in seven camps in Nepal's Jhapa and Morang districts. These refugees began entering Nepal in late 1990; the influx peaked in the first half of 1992. Since the beginning of 1998 no new arrivals have been accepted by His Majesty's Government of Nepal (HMGN). The refugees, who are mostly ethnic Nepali speaking groups from the southern plains of Bhutan, fled their country in fear of the enforcement of new citizenship laws and the "one nation, one people" policy of cultural assimilation in the late 1980's. Seven official ministerial-level talks have been held between the Bhutanese government and HMGN without any effective resolution being achieved thus far - this indicates that the problem is unlikely to be resolved in the near future.

The natural increase in the refugee population has declined over the years and is currently 2% per year, reflecting the effective family planning campaigns and the education efforts in the camps. The population is young with 47% under the age of 17 years and a large and growing number of up to nearly 18,000 individuals who were born in the camps. A total of 5% are over the age of 60 years.

General health and nutritional situation

The health and nutrition of the camps is generally stable. The prevalence of wasting and mortality rates have been maintained at low levels. Average CMR is 0.84/10,000/day and the under-five mortality rate is 1.35/10,000/day. The latest SCF-UK survey in June 1998 reported a prevalence of acute wasting of 4.3% and 0.5% severe wasting. The incidence of acute wasting has remained low since this time (UNHCR - 18/05/99). It should be noted, however, that this survey showed that only 57% of the undernourished children sampled were enrolled in the selective feeding programme. No serious epidemics have been reported. Health-related needs are adequately covered by SCF-UK and referrals to the district and regional health facilities for those requiring special medical treatment. Sanitary conditions in the camp are also reported to be satisfactory. An uninterrupted and adequate (approximately 22 litres/person/day) supply of chlorinated water was available in all camps throughout 1998. The proper disposal o human waste and vector control is well managed (SCF-UK - 05/99; UNHCR -18/05/99; WFP - 11/06/99).

Micronutrient deficiencies

Concerns raised in the previous issue of RNIS about a possible increase in micronutrient deficiency disorders (MDD) following the withdrawal of fortified blended food from the general ration have been confirmed. Since the beginning of 1999, there has been a steep increase in the number of cases of angular stomatitis - vitamin B2 deficiency (see graph). Micronutrient deficiency disorders have been the main nutritional problem reported among these refugees, dating back to shortly after their arrival in Nepal 1992. A range of strategies have been put in place to address this problem, including in particular, the inclusion of parboiled rice (rather than polished rice), fortified blended food and vegetables in the general ration. Iodized salt and vegetable oil fortified with vitamin A is also included in the ration. These changes were accompanied by nutrition information and communication campaigns related to the washing of rice and the health benefits of parboiled rice and blended food. These combined strategies were followed by significant reductions in levels of MDDs and greater awareness on the part of the community (Mears -1995).

Trend for Angular Stomatitis

Note that angular stomatitis can be confused with viral infections of the mouth and although it has not been possible to confirm through biochemical assay that the current increased incidence is attributable to B2 deficiency, most cases have been successfully treated with a one week course of vitamin B complex tablets (SCF - 9/06/99). Responding to treatment is often taken as confirmation of micronutrient deficiency, where facilities for biochemical analysis are unavailable (there are no facilities in Nepal).

The incidence rates of a range of micronutrient deficiency incidences for 1999 and 1998 are shown in the table. The graph shows the increase in incidence in the first four months of 1999. The incidence varied between camps and was as high as 44.5/1,000/month in Khundunabari camp. The rate was similar in both sexes, but highest (almost twice as common) in the 5-18 year old age group. According to SCF the disease is rarely seen among people who are in supplementary feeding (SCF - 09/06/99).

Disease/deficiency	Jan.-Apr. 1998 (per 1.000/month)	Jan.-Apr. 1999 (per 1,000/month)
Vitamin A deficiency (eye signs)	0.33	0.27
Mild Beriberi	3.2	2.5
Severe Beriberi	0.06	0.11
Angular Stomatitis	5.97	24.2
Scurvy	0.54	0.76
Pellagra	00	0.01

An insufficient intake of riboflavins causes Angular stomatitis. Other points to note about the distribution of the disease in this refugee population include:

· The withdrawal of blended food from the standard ration at the end of 1998 reduced the amount of vitamin-B2 available in the diet (see RNIS 26). The current general ration provides 0.37 mg vitamin-B2, which is only about one third WHO minimum recommended daily requirements for emergency affected populations (1.4 mg) (WFP - 11/06/99; WHO, 1997)

· The camps in which refugees have more opportunities to earn income and supplement their rations have lower levels of angular stomatitis, whereas the more restrictive camps, particularly Kundunabari reported the highest incidences of angular stomatitis.

· The incidence was lower amongst those families who said they consumed more green leafy vegetables (SCF - 09/06/99).

· Refugee families with an additional income source (e.g.: a member earning incentive payments) have lower incidences (SCF - 09/06/99).

· The supply of fresh fruit and vegetables to the camps to supplement the general ration, which is the responsibility of UNHCR, has been very erratic and often during the past fifteen months (January 1998 to March 1999) the supply has fallen short of the agreed requirements by the following amounts (WFP -11/06/99):

· The aetiology of micronutrient deficiencies among these refugees is no doubt complex, with a range of contributing risk factors. The response strategies available to address these problems are limited, and to be most effective a range of combined strategies are usually applied. The withdrawal or failure of key strategies to prevent micronutrient deficiency diseases, such as the distribution of vegetables and blended foods, places these vulnerable refugee populations at increased risk.

· In prior years the incidence of angular stomatitis was always higher amongst the under five year olds compared to those aged 5 to 18 years. That the problem is now more prominent amongst the school age group is unexplained (WFP -11/06/99).

Overall, the nutritional situation of the Bhutanese refugees appears to have stabilised, although the history of micronutrient deficiency disorders in this population and current concerns about increased incidence of angular stomatitis mean that they are considered at moderate nutritional risk (category IIb).

Priorities and Recommendations:-

In terms of the micronutrient problem:

· In the short/immediate term the UNHCR/WFP food assessment mission recommended that the most vulnerable group, children under five years old, be provided with an emergency supply of blended food for the next three months. However, given the obvious nutritional benefits of blended food, every possible consideration should be given to reinstating blended food as part of the general ration, or at the very least extending the target group for blended food to include older children and adolescents, who suffered higher incidence of angular stomatitis.

· UNHCR should explore every possibility for the timely procurement and regular delivery of green vegetables to the camps. Contractual arrangements with vegetable suppliers should be scrutinised with a view to improving the delivery of vegetables according to the requirements of the programme and providing green vegetables to the greatest extent possible.

· UNHCR spends over US$ 500,000 annually for the purchase of vegetables from external suppliers. UNHCR, Nepalese Red Cross Society (NRCS) and Helen Keller International (HKI) should explore the possibility of promoting large scale, and possibly irrigated, green vegetable production in local villages surrounding the camps. The produce could be bought by UNHCR and supplied to the refugees through NRCS.

· WFP's new home gardening project, which is being implemented by HKI and NRCS, offers the potential to increase the production of green vegetables within the camps. This project should move quickly to incorporate all of the camps with maximum coverage of the refugee communities as soon as possible. Those refugee families with extremely limited space should be encouraged and allowed to cultivate vegetables in public areas within the camps (school grounds, health centres, etc.).

· In the same context, other efforts to further address micronutrient deficiencies should be supported. For example, evaluating and developing the WFP-sponsored backyard poultry project (launched mid-1998 in Khudunabari and Goldap, but soon stopped due to apparent non-acceptance by refugee organisations and camp authorities).

· Regular nutritional surveys (that also track micronutrient deficiencies) should be undertaken every six months (or even on quarterly basis when nutritional problems persist).

· Given that the majority of the refugees have been in the camps for eight years, a long-term view must be taken. More active encouragement is required to provide an effective enabling environment so that the refugees can continue to better meet their needs. It is necessary for the refugees to be given every opportunity to supplement their food requirements through improving the potential for own-production, or through income earning activities. There is also a need for support to better equip the refugees for their self-reliance and repatriation in the future. As part of this strategy, the implementation of refugee food assistance as well as WFP-sponsored income generating, vocational training and home gardening activities should be encouraged.

· The current level of assistance for non-food items (i.e., kerosene, soap, stoves, replacement parts etc.) is adequate and should be maintained. An urgent alternative to the lack of funding from NRCS/IFRC for the provision of clothing during 1999 is required. The ration composition and scale for the supplementary feeding programme should be maintained for malnourished children, pregnant and nursing women, and TB and elderly sick patients needing intensive support. Efforts to increase programme coverage must be made.